Tell Us A Little About Your Business

General Information:

Business Address:

Year Business Was Established:

Legal Entity Type:

Please Provide Legal Entity Type:

States of Operation (licensed jurisdictions and physical locations)

Annual Revenue:

3 Years ago ($):

2 Years ago ($):

Last Year ($):

Current Year Projection ($):

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Have you had a bankruptcy, foreclosure, lien, or judgment in last 5 years?

Anticipated ownership, service, or operational changes in next 12 months?

Any non-renewals/cancellations in last 3 years?

Any loss runs available for past 5 years?

Claim Details:

Any claims in the last 5 years?

Claim Type (property damage, bodily injury claims, employee injury claims, fire, etc.):

Amount ($):

Outcome (Paid, Pending, Settled...):

Ownership Structure / Affiliations:

Are you owned by or do you own another entity?

Do you or a related entity provide services for a project where you hold over 20% ownership?

Please Provide Details

Employees & Contractors:

Principals / Partners / Officers (#)

Licensed Design Professionals (#)

Interns / Trainees / EITs (#)

Admin / Office Staff (#)

Do you use sub-contractors?

What % of your project work is done by sub-contractors?

Estimated annual sub-contractor cost ($):

Estimated Annual Payroll ($):